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AFFIDAVIT — DECLARATION OF CURRENT YEAR’S GROSS INCOME Republic of the Philippines ) Province of NCR ) City/Municipality of __— ) 1 also known as of legal age Single / Married, residing at after being sworn in accordance with law, depose and say that: 1. receive professional / talent / service fees as, / | Practice of Profession / / Management & Technical Consultants / [ Professional Entertainment / | Bookkeeping agents & agencies / [ Professional Athlete / / Director who is not employee of the company / Others; Specify. / / Judicial person in the practice of profession 2. Assuch, Ihave received a gross income of P for the current year as of 2015. 3. 1am executing this Affidavit-Declaration as a requirement of Revenue Regulation No. 30 - 2003 of the Bureau of Internal Revenue in the determination of the applicable creditable withholding tax rate (10% or 159) to be imposed by withholding agent/s. IN WITNESS WHEREOF, | have hereunto set my hand this day of in the municipality of province of. Philippines. Affiant - Declarant TIN#. SUBSCRIBED AND SWORN to before me, in this day of with Community Certificate No. issued at on 20_. Dac No, Page No. Book No. Series of 2015 iia DATE FROM PHILIPPINE TUBERCULOSIS SOCIETY. IN June 8, 2015 PTSI/QU Branches Consultants Finance Department REVENUE REGULATIONS NO. 30-2003 This will serve as your reminder to furnish, the Finance Department a copy of your notarized sworn declaration filed and submitted to the BIR every June 30 of each year, to disclose your respective income for the current year, pursuant to BIR Revenue Regulation No. 30-2003 dated December 15, 2003. ‘The document will facilitate the Finance Department to determine the applicable tax rate (10% or 15%) to be applied / withheld from your professional fees. Please refer to the attached copy of BIR Revenue Regulation No. 30-2003. PTSI/QI Consultants shall furnish each payor of their professional fees a copy of the duly stamped received sworn declaration not later than 5 days from the date of receipt by the BIR. Failure to submit to the payor a copy thereof shall withheld the tax at the rate of 15%. For your information and guidance. Noted by: ELIZABETH V. CADENAM.D. Executive Director of e:Ofce ofthe Exoouve Director HRAdmin FoD Finance Qt Training Research Consultant Finance Controller